Patients commonly present to us for evaluation of recurrent sinusitis, ear infections, chronic nasal congestion and difficulty breathing through their nose. Allergies can play a major role in many of these problems. As Otolaryngologists (ENTs), we are in the unique position to treat these issues both medically and surgically.
What to expect at your visit:
- Complete History focusing on your concerns
- Physical Exam including comprehensive evaluation of the ears, nose and throat
- In office Skin Testing for Environmental Allergens
- Order Blood Allergy Testing if you are not a candidate for skin testing
Discuss Treatment including Sublingual Immune Therapy – The NO SHOT approach!
Hootan Zandifar, MD
BECOME OUR PATIENT
The first step is to call our office to schedule an appointment. (310)657-0123. Our patient care coordinator will obtain the information needed to schedule your appointment and provide you with the specific forms you will need to fill out before your visit. If you are interested in allergy skin testing, review all of your medications both prescription and over the counter including herbs with our patient care coordinator, as many of these can affect test results and may need to be stopped prior for 2 weeks to your visit if possible. Please bring any prior allergy test results as well as a list of current and past medications.
OBTAIN AN EVALUATION
Dr. Zandifar will review your history and perform a physical exam. The doctor will then discuss options of allergy testing with you, and together you can decide whether skin or blood testing is most appropriate for you.
Allergy testing looks for responses to the most common allergens in the area, including weeds, grasses, trees, dog, cat, dust, dust mites and molds. Skin testing can be done in the office with the results available the same day. Skin testing does not require needles or shots. You may wear normal clothes to the test. You will just need to roll up your sleeves to expose your lower arms. Children may need to have the testing done on their backs if there is not enough room on their arms. In this case, they will need to pull up their shirt for the test. Parents may stay with their child during testing.
Prior to testing you will be asked to complete an allergy questionnaire and consent form. The technician will wipe both arms with an alcohol swab to clean the area to be tested. A pen will be used to make letter markings on the arms to indicate the allergen test sites.
One drop of each allergen, the substances which are possibly causing the allergy symptoms, is placed on the skin of the arms or back with a plastic device which is usually not painful. This process takes just a few minutes. The allergens are left in place for 20 minutes. During this time the arms may itch but it is important not to scratch. We encourage parents to reassure their children though out this process. You can hold their hands and provide distraction.
After 20 minutes, the skin is inspected for a wheal (red raised bump) at each allergen site which indicates a positive allergic reaction to that substance. The size of the bump will be measured.
After the results are read, the test sites are wiped again with an alcohol swap. The test sites are usually red and itchy. Topical Benadryl or cortisone cream is applied for relief. This usually goes away within 30 minutes but can last a few hours. You must be off any medications that could interfere with skin reaction for 2 weeks prior to skin testing so it will not affect the results.
If you are unable to come off your medications or cannot tolerate skin testing, blood can be sent for allergy testing. The same allergens are tested for by blood testing as skin testing. You will be given an order for the blood allergy testing which you will take to an outside lab, most often Quest. At the lab, the blood will be drawn and the testing performed. There is a Quest lab located across the street from our office that you can walk to and have your labs drawn the same day. You can also schedule your appointment with a Quest lab in the future at your convenience. The results of blood testing are usually known in about one to two weeks.
Common Reasons Allergy Skin Testing Would Not be Preformed:
Patient unable to stop taking medications which interfere with skin testing*
History of Anaphylaxis
*If you are interested in skin testing, please call the office ahead of your appointment to review all of your medications including over the counter medications, herbals and home remedies as these could affect the test results.
DEVELOP A TREATMENT PLAN
Based on your history, physical exam and the allergy test results, appropriate treatment options will be reviewed. These include environmental measures, nasal sprays (saline, antihistamines and steroids), oral medications (antihistamines, Singulair) and sublingual immune therapy (the NO shot approach!). We will discuss how allergies are contributing to you problems. We will review how to decrease your exposure to your allergens. We will recommend appropriate medications to help control your allergy symptoms. We will also determine if surgery is appropriate for anatomical factors contributing to your symptoms.
SUBLINGUAL IMMUNE THERAPY (THE NO SHOT APPROACH!)
The goal of both allergy shots and sublingual therapy is to alter the body’s immune system response to the allergens. Sublingual immunotherapy (SLIT) is similar to allergy shots but the medication is given as a drop under the tongue rather than by a shot. Your allergy drops are made specifically for you based on the results of your allergy testing. The first dose of each new allergy treatment is given to you in our office and you are observed 20 minutes afterwards for a reaction. SLIT is taken daily at home by applying 1 drop under the tongue and keeping it there for 1 minute before swallowing for the first week then increasing to 2 drops for the next 3 weeks.
For the first 4 months, SLIT requires a monthly visit to our office to pick up your new allergy vial and receive your first drop. After 4 months the maintenance dose is reached, at which point the new medication vial can be picked up or mailed to you every 2 months. You will need a visit with the doctor every 6 months to review your progress and allergy management.
Unfortunately the benefit of SLIT is not seen immediately. It takes time for the body to change it’s response to the allergic substance(s). You will need to continue on your allergy medications for symptomatic relief during this process. You may start to notice symptom improvement after 6 months of therapy. Therapy is usually continued for 1 to 3 years in order maintain long term control of symptoms. The goal is a maintained clinical improvement in allergic symptoms and a reduced need for medications.
There are many advantages to SLIT compared to allergy shots:
Administered at home
Avoid weekly doctor visits
Much lower risk of anaphylactic reaction to the treatment
What about testing for Food Allergies?
Many patients ask us if they need to be tested for food allergies. Testing is recommended when there is clinical concern for a food allergy. Food allergies may be suspected if there is a history of anaphylaxis, angioedema, a reaction occurring within minutes to hours of ingesting food, moderate to severe atopic dermatitis, Eosinophilic Esophagitis or other specific GI disorders. We do not skin test for food allergies in our office but if a food allergy is suspected blood testing can be ordered. Blood testing can identify foods that potentially provoke a food induced allergic reaction, but the tests alone are not diagnostic of food allergies.
When a patient is diagnosed with a food allergy, avoidance of the food is first line therapy. Prescriptions for automatic epinephrine injectors (such as Epi Pens) are given to patients diagnosed with food allergies. Patients and families are instructed in emergency management including appropriate epinephrine administration.
I have been allergy tested before do I need to be tested again?
An allergic profile can change over time so if it has been over a year since the last allergy testing or symptoms have changed, repeat allergy testing may be recommended. Please bring a copy of your prior allergy testing for our review.
Why do you or your child need to be allergy tested?
In addition to confirming you are allergic, it helps to know what you are allergic to. Once you know what you are allergic to you can avoid or reduce time of exposure to allergen triggers as well as know when to use medications. Many parents are concerned about their children being on chronic medications so once a child’s allergies are identified, medications can be tailored as well as determining when the medications need to be taken. If allergy testing is positive, you can also discuss immune therapy which is the only know method to treat the cause of allergies.
Allergies can contribute to:
- Chronic runny nose
- Chronic nasal congestion
- Chronic mouth breathing which can affect dentition and mid-face growth
- Recurrent Ear Infections, Eustachian Tube Dysfunction, Persistent Ear Fluid
- Recurrent Sinusitis, Nasal Polyps
- Changes of the voice
You can have a runny nose from a “cold”, sinusitis or allergies. It is sometimes hard to distinguish between the three especially if you feel you always have a runny nose. Allergy testing can be performed to determine if you have allergies as well as what you are allergic to.
Allergies can cause swelling of the lining of the nose and contribute to the enlargement of the adenoids which can make it difficult to breathe through the nose. When the nose is blocked, it can cause a “nasal” sounding voice, mouth breathing and snoring. Long term nasal obstruction resulting in chronic mouth breathing can potentially affect teeth alignment and facial growth. Often in addition to treating the allergies, surgery is considered to manage enlarged turbinates and adenoids.
When the back of the nose is blocked, it can also affect the function of the Eustachian tube. The Eustachian tube connects the nose and the middle ear. It is responsible for regulating the pressure in the middle ear. When the middle ear is not ventilated well negative pressure or fluid may develop. This can lead to hearing loss or infection. Placement of ear tubes is often recommended for recurrent ear infections or persistent fluid.
Allergies can cause swelling of the lining of the nose blocking the drainage passageways of the sinuses. In some cases, allergies can cause polyps which are soft noncancerous growths that arise from inflamed edematous nasal mucosa. Polyps can become large and occur in clusters like grapes blocking the nasal passages and sinus openings.
Sinusitis occurs when there is inflammation and swelling of the lining of the sinuses causing pressure and pain. This is often accompanied by fluid becoming trapped in the sinuses and then secondarily infected. Sinusitis is usually treated with antibiotics and medications that reduce swelling in the nose. Underlying allergies must be treated when they are a contributing cause to recurrent sinusitis. When medications are not effective or there is an underlying anatomical problem, surgery may be necessary to open the sinuses.
Allergies can also contribute to changes in the voice. When the nasal cavity is blocked from enlarged and swollen tissue, sounds cannot vibrate through the open space in the nose as they should. This decrease in resonance results in what many people describe as a “nasal” sounding voice. Allergy suffers can also develop hoarseness from throat clearing and coughing secondary to post nasal drip or an itch in their throat. Over time chronic throat clearing and coughing can cause damage to the vocal cords resulting in permanent damage.
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